By Anita Johnston-Early

2C North is a unit that can boast of few physical amenities. The architecture is antiquated; private and semi-private rooms and bathrooms are scarce. It is where patients come for treatment if they have cancer of the lung, prostate, liver, or stomach, or mycosis fungoides, a rare lymphoma.

Some might reject 2C North at first glance, or cringe at sharing a room with three patients. A few would find it distasteful to walk down a corridor to a bathroom. Some would have to be convinced that the treatment here is very good and not easily duplicated elsewhere.

But because of the superb care given by a caring staff, the environmental inadequacies of 2C North are hardly noticeable.

2C North restores those whose emotional reserves have been severely depleted by the shock of

ANITA JOHNSTON-EARLY. RN. is oncology nurse investigator and protocol coordinator, Veterans Administration Center, Washington, DC.

knowing that they have cancer. Where the earth once had been crumbling beneath, 2C North builds a firm foundation. Nurses on 2C North are not afraid to touch and hold or to speak about cancer and dying. Baths and bedmaking are often delayed as nurse and patient sit side by side assuring, listening, and sharing. Together, we ask what can be done today to make life more pleasant, what can be achieved with the resources at hand. Nurse, patient, family, and doctor rejoice together when an x-ray shows that a tumor is shrinking. And when it is painfully clear that treatment has failed and there is no where to go but into somebody's arms, those arms are waiting on 2C North.

The 2C North nursing staff is involved. They are sometimes warned that involvement might mean a lack of objectivity, but they have learned long ago that the opposite is true. Involvement is not only productive, it is also natural. Yet since it can be draining, the nurses are advised and supported by a psychiatrist, who years ago was an intern on 2C North. With him, they learn to deal with their emotions

and get to the core of problems. The staff are able to pool and comple ment their strengths so effectively that together, they have become an imposing force.

Empathy is the unit's most valuable characteristic. Indeed, it is difficult not to learn it; for superficiality is quickly abandoned in the face of acute hurt and need. Patients and families continually teach and reinforce the concept of empa thy in one another. Roger and his mother are two of many we have learned from.

Roger was an unassuming 38year old patient who came to us from Appalachia. His cancer was so widely spread that we could hope only for a transitory remission of his disease; that's all he ever had. After a six-week hospitalization for intensive chemotherapy, Roger was discharged to return every three weeks for maintenance treatment. Within a few months his cancer, again growing, was unresponsive to new treatment. Roger was not sorrowful He did not complain. He just accepted what was happening.

He asked that his mother be I called to share his last days with

him. She arrived carrying only a paper sack. She remained at his side, helping the nurses bathe and turn his now edematous and jaundiced body. She slept in a chair when he slept. She coaxed broth into his ulcerated mouth and gently rubbed his aching limbs. A touch, a glance, words of assurance and encouragement communicated that this was just another hardship to be endured. They had put up with plenty before, and they could get through this now. Roger wasn't to worry, "because she'd be just fine." He would smile at her confidence and then sleep again for a while.

When it was obvious that he was dying, Roger called his mother to his side and whispered his goodbye. When he died, she turned from him, seeming to accept her fate as he had, and left his room carrying her paper sack.

It was hard for those of us who had shared those days with her to Say good-bye. We felt a kinship with her and she with us. Many of our patients and families spend weeks, months, and even years undergoing treatment. The bonds between us grow, regardless of how much time we have together. During holidays, many family members return to reminisce and bring gifts. Occasionally, they telephone or write as new adjustments are being made in their lives. And then one day we realize we haven't heard from one of them in a long time, and we know that for him or her, adjustment is complete.

While the greatest nursing contributions we make are in day-today bedside care for patients, we have made other unique and worthy contributions. One had to do with the care of the patient with mycosis fungoides (MF). MF begins with skin tumors, ulcers, or plaques that are sometimes thick and leathery. Because MF is difficult to diagnose in its early stages, patients often spend years going from doctor to doctor. At diagnosis they may be bitter, depressed, and withdrawn.

The skin lesions break down, become infected, and drain. The odor is repulsive. Often a person's entire skin surface is involved. Intravenous therapy becomes difficult to administer, and bathing and topi

cal application of creams tedious and unpleasant. Eventually the internal organs are affected. The disease now becomes fatal.

Alice is the research nurse in charge of MF patients on 2C North. She is young and pretty, with clear, smooth skin. It is impossible not to be struck by the physical contrast between patient and nurse. But Alice seems to see past the smelling, oozing lesions. She patiently instructs each person in the use of topical chemotherapy and creams, using video tapes that she has prepared. She, listens attentively as patients repeat the instructions back to her. With proficiency she gives Iv therapy in veins hidden beneath hard plaques.

Alice faithfully supports her patients through the slow and difficult months of electron beam therapy that sometimes further damages the skin by reddening or burning it. She gives her patients jobs to do to help them remain productive and offers suggestions on how to make positive changes in their lives. She helps her patients develop inner resources that strengthen their personalities. Based on her experience with MF, Alice has written several papers that not only provide guidance on various aspects of the disease, but also give insight into support of cancer patients in general.

Making a difference in each patient's care is the norm on 2C North. But the nurses also have unique opportunities to do clinical research that can affect the lives of many patients. One nurse conducting studies in lung cancer noticed that a large percentage of her longsurviving patients with small-cell lung cancer had stopped smoking at or before their cancer was diagnosed. All had previously been heavy smokers. She had not been asked to record this information, but because she knew her patients so well, this phenomenon became apparent to her. She began keeping records on new patients, and after several years, her suspicions were confirmed: The patients who had stopped smoking at or before diagnosis had a better response to treatment than those who continued to smoke. These results were published in a major medical journal and

widely circulated by the press. The finding prompted physicians to advise their patients that smoking abstinence was an aid to treatment. It encouraged scientists to test whether smoking abstinence was asso ciated with longer survival.

Another challenge that became a triumph concerned patients whose tumors obstruct large and small airways so that their lungs can no longer accommodate oxygen, causing these patients to smother While these individuals were clearly suffering, the medical and nursing staff often treated symptoms inadequately because they feared that narcotics would further interfere with respiratory function. Some stood by helplessly, but other nurses prodded the medical staff into ac tion. Finally, all physicians and nurses became convinced that they were obligated to intervene aggressively and treat pain, anxiety, and shortness of breath.

I became principal investigator to study safety on the efficacy of continuous IV morphine in the patient with intractable pain and dyspnea. We formulated a plan to deliver continuous intravenous morphine to those patients for whom all other analgesic regimens have failed. Patients were monitored so that medication would not depress an already compromised respiratory system. Pain was safely relieved as were anxiety and dyspnea. Our head nurse reported the preliminary results at an Oncology Nursing Society meeting. Yes, it was possible, with careful monitoring and titration of medication, to significantly relieve the suffering of these patients. This report was one of 40 publications initiated or aided by 2C North nurses.

2C North is a model nursing unit. In this environment, nurses can develop their full abilities regardless of academic background. They are given the opportunity to develop patient management programs and the flexibility to implement them. Nurses not only give care, they develop better care.

'Johnston-Early Anita, and others. Smoking abstinence and small cell lung cancer an association, JAMA 244 2175-2179, Nov 14, 1980. **Paper presented at American Society of Clinical Oncology meeting. May 24, 1983.

American Journal of Nursing/August 1983 1183